The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Mechanical Circulatory Support Devices and is brought to you by Jenna Pallansch, MD, Morgan Penzler, MD, Gabriella Rivera Camacho, MD, Blaire Langa, NP, Claire Lawson, NP, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and Richard Musialowski, MD.
EMGuideWire's Radiology Reading Room: Stress-Induced CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Stress-Induced Cardiomyopathy and is brought to you by Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA, Emily Lipsitz, PA, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and John Symanski, MD.
EMGuideWire's Radiology Reading Room: Hypertrophic CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Hypertrophic Cardiomyopathy and is brought to you by Ashley Moore-Gibbs, DNP, Claire Lawson, NP, Laszlo Littmann, MD, and John Symanski, MD.
Dr. Escobar’s CMC X-Ray Mastery Project: December CasesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Blunt hemothorax
- Pulmonary contusion
- Lung Cancer with Bone Metastases
- Pneumomediastinum
- Pneumopericardium
EMGuideWire's Radiology Reading Room: Situs AnomaliesSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Situs Anomalies and is brought to you by Dominic Nicacio, MD, Andrew Yde, MD, Jorge Alegria, MD, and Laszlo Littmann, MD.
EMGuideWire's Radiology Reading Room: Peripartum CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Peripartum Cardiomyopathy and is brought to you by Kaley El-Arab, MD, Blaire Langa, NP, Claire Lawson, NP, and Ashley Moore Gibbs, DNP. It is has the special guest editors: Richard Musialowski, MD and Laszlo Littmann, MD.
EMGuideWire's Radiology Reading Room: Blunt Aortic InjurySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Blunt Aortic Injury and is brought to you by Rachel Plate, MD and Oriane Longerstaey, MD. It is has special guest editors: Bryant Allen, MD
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: March CasesSean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Emphysematous cholecystitis
• Pyelonephritis
• Perinephric abscess
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January CasesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. Lauren Ramsey, PA-C works with the Sanger Heart & Vascular Institute. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Atrial Myxoma
- Cardiac Lymphoma
- Small Cell Lung Cancer
- Metastatic Cervical Squamous Carcinoma
- Spontaneous Pneumothorax
EMGuideWire's Radiology Reading Room: Stress-Induced CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Stress-Induced Cardiomyopathy and is brought to you by Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA, Emily Lipsitz, PA, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and John Symanski, MD.
EMGuideWire's Radiology Reading Room: Hypertrophic CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Hypertrophic Cardiomyopathy and is brought to you by Ashley Moore-Gibbs, DNP, Claire Lawson, NP, Laszlo Littmann, MD, and John Symanski, MD.
Dr. Escobar’s CMC X-Ray Mastery Project: December CasesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Blunt hemothorax
- Pulmonary contusion
- Lung Cancer with Bone Metastases
- Pneumomediastinum
- Pneumopericardium
EMGuideWire's Radiology Reading Room: Situs AnomaliesSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Situs Anomalies and is brought to you by Dominic Nicacio, MD, Andrew Yde, MD, Jorge Alegria, MD, and Laszlo Littmann, MD.
EMGuideWire's Radiology Reading Room: Peripartum CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Peripartum Cardiomyopathy and is brought to you by Kaley El-Arab, MD, Blaire Langa, NP, Claire Lawson, NP, and Ashley Moore Gibbs, DNP. It is has the special guest editors: Richard Musialowski, MD and Laszlo Littmann, MD.
EMGuideWire's Radiology Reading Room: Blunt Aortic InjurySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Blunt Aortic Injury and is brought to you by Rachel Plate, MD and Oriane Longerstaey, MD. It is has special guest editors: Bryant Allen, MD
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: March CasesSean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Emphysematous cholecystitis
• Pyelonephritis
• Perinephric abscess
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January CasesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. Lauren Ramsey, PA-C works with the Sanger Heart & Vascular Institute. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Atrial Myxoma
- Cardiac Lymphoma
- Small Cell Lung Cancer
- Metastatic Cervical Squamous Carcinoma
- Spontaneous Pneumothorax
Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: September CasesSean M. Fox
Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
• Aortic Transection
• Hemothorax
• Innominate Artery Transection
• Dextrocardia
• Situs Inversus
• Pneumonia
• Complete Lung Consolidation
• Septic Pulmonary Emboli
• Pulmonary Metastases
• Pneumothorax
EMGuideWire's Radiology Reading Room on Pediatric Adult Aortic CoarctationSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pediatric and Adult Aortic Coarctation and is brought to you by Jennifer Potter, MD and Elizabeth Olson, MD.
EMGuideWire's Radiology Reading Room: Pericardial EffusionSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Spontaneous Pericardial Effusion and is brought to you by Chelsea Wilson, MD, and Emily Lipsitz, PA-C.
EMGuideWire's Radiology Reading Room: Septic Pulmonary EmboliSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Septic Pulmonary Emboli and is brought to you by Victoria Serven, MD, Travis Barlock, MD, and Katherine Sillman, NP.
Dr. Michael Gibbs's CMC X-Ray Mastery Project: June casesSean M. Fox
This document provides an overview of the monthly adult chest x-ray cases from the Emergency Medicine department. It discusses cases submitted from partners in Brazil and Tanzania. The cases this month included alveolar hemorrhage from Goodpasture's syndrome, rib fractures with tension hemothorax from a motor vehicle collision, rib fractures with flail chest from a fall, traumatic aortic disruption from a pedestrian being struck, active tuberculosis, and transfusion related acute lung injury. The goal is to promote widespread mastery of chest x-ray interpretation and share cases between various international contributors.
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: August C...Sean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Splenic Rupture
• Obstructive jaundice
• Ovarian Torsion
Drs. Milam and Thomas's CMC X-Ray Mastery Project: November CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on: Pericardial Effusion, Vaping Lung Injury, Cavitary Pulmonary Abscess, Esophageal Foreign Body, Dilated Cardiomyopathy, Acute Aortic Dissection, Pneumomediastinum, Massive Pneumoperitoneum, Malignant Pleuarl Effusion, Right Sided Aortic Arch, RLL pneumonia
Drs. Lorenzen and Escobar’s CMC X-Ray Mastery Project: August CasesSean M. Fox
This document provides a summary of adult chest x-rays reviewed from the Emergency Medicine department. It discusses various cases seen over the past month, including a malignant pleural effusion with lung mass from uterine cancer, pericardial effusions, traumatic aortic disruption from motor vehicle accidents, a case of femoral guidewire migration in an ICU patient, a disconnected HeRO graft in a dialysis patient, and a case of right-sided flail chest and pulmonary contusion from a motor vehicle crash. The document aims to promote mastery of chest x-ray interpretation among emergency medicine residents.
EMGuideWire's Radiology Reading Room: Diaphragm Injury CasesSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Diaphragm Injury and is brought to you by Jacob Leedekerken, MD, Chelsea Wilson, MD, and Travis Barlock, MD. It is has special guest editor: Kyle Cunningham, MD
Drs. Milam and Thomas's CMC X-Ray Mastery Project: April CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Esophageal Perforation
• Perforated Viscous
• Pneumothorax
• Traumatic Diaphragmatic Hernia
• Pulmonary Contusion
• COVID-19 associated Pneumonia
• COVID-19
• Influenza Like Illness
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #3 CasesSean M. Fox
This document summarizes a weekly chest x-ray interpretation session. It discusses various cases presented including pericardial effusions, pneumothoraces, thoracic aneurysm, malignant pleural effusions, cardiomegaly, pneumonia, and bronchogenic carcinoma. The goal is to promote mastery of chest x-ray interpretation among emergency medicine residents and other specialties. Cases are anonymized and discussed to analyze cardiac and pulmonary anatomy and diagnose common chest pathologies.
EMGuideWire's Radiology Reading Room: Lung CancerSean M. Fox
This document discusses case studies of primary and metastatic lung cancer seen on chest x-rays. It begins with an introduction to the contributors and goals of the case study series. Several cases are then presented and discussed, including examples of primary lung cancers, metastatic cancers to the lungs from other organs, and malignant pleural effusions. Risk factors, diagnostic imaging, staging, and treatment options for both small cell and non-small cell lung cancers are also reviewed.
EMGuideWire's Radiology Reading Room: Spontaneous PneumothoraxSean M. Fox
This document discusses the management of spontaneous pneumothorax. It provides guidelines for treating primary and secondary spontaneous pneumothorax, including observation for small pneumothoraces and chest tube insertion for large or unstable patients. Recent studies have found conservative management without intervention may be sufficient and safer than interventional treatment for moderate to large primary pneumothoraces. Needle aspiration appears to be as effective as small bore chest tubes with a lower risk of complications.
Drs. Escobar’s CMC X-Ray Mastery Project: November CasesSean M. Fox
Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. They are joined by Marianne Dannemiller, PA who is an APP for Sanger Heat & Vascular Institute. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Aortic Aneursym
- Endovascular Aortic Repair (EVAR)
- EVAR Endoleak
- Right Sided Aortic Arch
- Tension Pneumothorax
- Thyroid Mass
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #6 CasesSean M. Fox
Dr. Michael Gibbs is a Professor of Emergency Medicine and interested in educating others. Radiology is a passion of his. Follow along with the EMGuideWire.com team as they post Dr. Gibbs's weekly educational, self-guided radiology slides on: Colonic perforation, free air, coarctation, multifocal pneumonia, several pneumothoraces, Oral Gastric Tube in right mainstem bronchus, Traumatic aortic disruption, Scoliosis, lung metastases, pneumomediastinum
Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: January CasesSean M. Fox
This document provides an overview of an ongoing chest x-ray interpretation series aimed at promoting mastery of chest x-ray interpretation. It discusses several cases presented in the series, including a perforated gastric ulcer, pulmonary arterial hypertension, a ruptured diaphragm, cavitary tuberculosis, pneumocystis pneumonia with spontaneous pneumothorax, and lower rib fractures with an associated splenic injury. The goal of the series is to teach anatomy and common pathologies through case examples. Contributors to the series come from various medical centers and specialties around the world.
Enf neuromusculares con fallo respiratoriouciguate
This document discusses neuromuscular disorders that can cause respiratory failure due to weakness of respiratory muscles. It describes the pathophysiology of respiratory failure in these disorders including weakness of the diaphragm, inspiratory and expiratory muscles. The diagnostic approach involves determining if respiratory failure is due to a cardiopulmonary or neurologic cause. If neurologic, further evaluating for underlying neuromuscular disorders through history, examination, electromyography and assessing respiratory muscle strength and function.
Drs. Lorenzen and Escobar’s CMC X-Ray Mastery Project: October CasesSean M. Fox
Drs. Breeanna Lorenzen and Daniel Escobar are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Disconnect VP shunt
- PFO Closure Device
- Implanted Baclofen Pump
- Pnuemobilia
- Common Bile Duct Stent
- Dextrocardia
- Implantable Cardioverter Device
- Left Ventricular Assist Device (LVAD)
1) Atrial septal defects are one of the most common types of pre-tricuspid shunts and can often remain asymptomatic until later in life when they may lead to heart failure, pulmonary hypertension, or arrhythmias if left unrepaired.
2) The natural history and prognosis of atrial septal defects depends on factors like the size of the defect and age at diagnosis, with smaller defects having higher rates of spontaneous closure and repair at a younger age leading to better outcomes.
3) Device or surgical closure of atrial septal defects can successfully close the defect and improve symptoms, but the best outcomes are seen in those with less elevated pulmonary pressures and cardiac chamber enlargement prior to repair
Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: March CasesSean M. Fox
Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
• Miliary tuberculosis
• Mediastinal mass
• Esophageal perforation
• Mucus plugging and left lung collapse
• Naloxone associated pulmonary edema
• Unilateral pulmonary edema in setting of severe Mitral Regurgitation
• ARDS and Ventilator-Acquired Pneumonia (VAP)
Drs. Pikus, Blackwell, Baumgarten, and Malloy-Posts’s CMC X-Ray Mastery Proje...Sean M. Fox
This document provides an overview of an ongoing chest x-ray interpretation series aimed at promoting mastery of chest x-ray interpretation. It discusses topics covered in prior presentations including peripartum cardiomyopathy, left ventricular assist devices, and pleural effusions. Appendices provide references for articles related to peripartum cardiomyopathy. The document also announces that next month's presentation will cover new diagnoses.
Dr. Cravens CMC Implanted Device Imaging Mastery Project: BiVentricular & Lea...Sean M. Fox
This document provides a summary of imaging and interpretation of biventricular pacemakers and leadless pacemakers. It describes the anatomy and placement of leads for biventricular pacemakers and ICDs. It also summarizes the indications for biventricular pacemakers in patients with heart failure and conduction abnormalities. The document further describes leadless pacemakers, including the Micra and Nanostim devices, and their benefits over traditional pacemakers in eliminating device-related complications. Potential candidates for leadless pacemakers include those with high-degree AV block or tachy-brady syndrome.
Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: September CasesSean M. Fox
Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
• Aortic Transection
• Hemothorax
• Innominate Artery Transection
• Dextrocardia
• Situs Inversus
• Pneumonia
• Complete Lung Consolidation
• Septic Pulmonary Emboli
• Pulmonary Metastases
• Pneumothorax
EMGuideWire's Radiology Reading Room on Pediatric Adult Aortic CoarctationSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pediatric and Adult Aortic Coarctation and is brought to you by Jennifer Potter, MD and Elizabeth Olson, MD.
EMGuideWire's Radiology Reading Room: Pericardial EffusionSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Spontaneous Pericardial Effusion and is brought to you by Chelsea Wilson, MD, and Emily Lipsitz, PA-C.
EMGuideWire's Radiology Reading Room: Septic Pulmonary EmboliSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Septic Pulmonary Emboli and is brought to you by Victoria Serven, MD, Travis Barlock, MD, and Katherine Sillman, NP.
Dr. Michael Gibbs's CMC X-Ray Mastery Project: June casesSean M. Fox
This document provides an overview of the monthly adult chest x-ray cases from the Emergency Medicine department. It discusses cases submitted from partners in Brazil and Tanzania. The cases this month included alveolar hemorrhage from Goodpasture's syndrome, rib fractures with tension hemothorax from a motor vehicle collision, rib fractures with flail chest from a fall, traumatic aortic disruption from a pedestrian being struck, active tuberculosis, and transfusion related acute lung injury. The goal is to promote widespread mastery of chest x-ray interpretation and share cases between various international contributors.
Drs. Lena, Avery, and Davis’s CMC Abdominal Imaging Mastery Project: August C...Sean M. Fox
Dr. Kelsey Lena is an Emergency Medicine Resident and Drs. Michael Avery and Joshua Davis are Surgery Residents at Carolinas Medical Center in Charlotte, NC. They are interested in medical education. With the guidance of Drs. Kyle Cunningham and Michael Gibbs, they aim to help augment our understanding of emergent abdominal imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides. This month’s topics include:
• Splenic Rupture
• Obstructive jaundice
• Ovarian Torsion
Drs. Milam and Thomas's CMC X-Ray Mastery Project: November CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on: Pericardial Effusion, Vaping Lung Injury, Cavitary Pulmonary Abscess, Esophageal Foreign Body, Dilated Cardiomyopathy, Acute Aortic Dissection, Pneumomediastinum, Massive Pneumoperitoneum, Malignant Pleuarl Effusion, Right Sided Aortic Arch, RLL pneumonia
Drs. Lorenzen and Escobar’s CMC X-Ray Mastery Project: August CasesSean M. Fox
This document provides a summary of adult chest x-rays reviewed from the Emergency Medicine department. It discusses various cases seen over the past month, including a malignant pleural effusion with lung mass from uterine cancer, pericardial effusions, traumatic aortic disruption from motor vehicle accidents, a case of femoral guidewire migration in an ICU patient, a disconnected HeRO graft in a dialysis patient, and a case of right-sided flail chest and pulmonary contusion from a motor vehicle crash. The document aims to promote mastery of chest x-ray interpretation among emergency medicine residents.
EMGuideWire's Radiology Reading Room: Diaphragm Injury CasesSean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Diaphragm Injury and is brought to you by Jacob Leedekerken, MD, Chelsea Wilson, MD, and Travis Barlock, MD. It is has special guest editor: Kyle Cunningham, MD
Drs. Milam and Thomas's CMC X-Ray Mastery Project: April CasesSean M. Fox
Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on:
• Esophageal Perforation
• Perforated Viscous
• Pneumothorax
• Traumatic Diaphragmatic Hernia
• Pulmonary Contusion
• COVID-19 associated Pneumonia
• COVID-19
• Influenza Like Illness
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #3 CasesSean M. Fox
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EMGuideWire's Radiology Reading Room: Lung CancerSean M. Fox
This document discusses case studies of primary and metastatic lung cancer seen on chest x-rays. It begins with an introduction to the contributors and goals of the case study series. Several cases are then presented and discussed, including examples of primary lung cancers, metastatic cancers to the lungs from other organs, and malignant pleural effusions. Risk factors, diagnostic imaging, staging, and treatment options for both small cell and non-small cell lung cancers are also reviewed.
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- Aortic Aneursym
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- Thyroid Mass
Dr. Michael Gibbs's CMC X-Ray Mastery Project - Week #6 CasesSean M. Fox
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Enf neuromusculares con fallo respiratoriouciguate
This document discusses neuromuscular disorders that can cause respiratory failure due to weakness of respiratory muscles. It describes the pathophysiology of respiratory failure in these disorders including weakness of the diaphragm, inspiratory and expiratory muscles. The diagnostic approach involves determining if respiratory failure is due to a cardiopulmonary or neurologic cause. If neurologic, further evaluating for underlying neuromuscular disorders through history, examination, electromyography and assessing respiratory muscle strength and function.
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Drs. Breeanna Lorenzen and Daniel Escobar are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
- Disconnect VP shunt
- PFO Closure Device
- Implanted Baclofen Pump
- Pnuemobilia
- Common Bile Duct Stent
- Dextrocardia
- Implantable Cardioverter Device
- Left Ventricular Assist Device (LVAD)
1) Atrial septal defects are one of the most common types of pre-tricuspid shunts and can often remain asymptomatic until later in life when they may lead to heart failure, pulmonary hypertension, or arrhythmias if left unrepaired.
2) The natural history and prognosis of atrial septal defects depends on factors like the size of the defect and age at diagnosis, with smaller defects having higher rates of spontaneous closure and repair at a younger age leading to better outcomes.
3) Device or surgical closure of atrial septal defects can successfully close the defect and improve symptoms, but the best outcomes are seen in those with less elevated pulmonary pressures and cardiac chamber enlargement prior to repair
Drs. Lorenzen and Barlock’s CMC X-Ray Mastery Project: March CasesSean M. Fox
Drs. Breeanna Lorenzen and Travis Barlock are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover:
• Miliary tuberculosis
• Mediastinal mass
• Esophageal perforation
• Mucus plugging and left lung collapse
• Naloxone associated pulmonary edema
• Unilateral pulmonary edema in setting of severe Mitral Regurgitation
• ARDS and Ventilator-Acquired Pneumonia (VAP)
Drs. Pikus, Blackwell, Baumgarten, and Malloy-Posts’s CMC X-Ray Mastery Proje...Sean M. Fox
This document provides an overview of an ongoing chest x-ray interpretation series aimed at promoting mastery of chest x-ray interpretation. It discusses topics covered in prior presentations including peripartum cardiomyopathy, left ventricular assist devices, and pleural effusions. Appendices provide references for articles related to peripartum cardiomyopathy. The document also announces that next month's presentation will cover new diagnoses.
Dr. Cravens CMC Implanted Device Imaging Mastery Project: BiVentricular & Lea...Sean M. Fox
This document provides a summary of imaging and interpretation of biventricular pacemakers and leadless pacemakers. It describes the anatomy and placement of leads for biventricular pacemakers and ICDs. It also summarizes the indications for biventricular pacemakers in patients with heart failure and conduction abnormalities. The document further describes leadless pacemakers, including the Micra and Nanostim devices, and their benefits over traditional pacemakers in eliminating device-related complications. Potential candidates for leadless pacemakers include those with high-degree AV block or tachy-brady syndrome.
Left ventricular assist devices (LVADs) can provide long-term support for patients with end-stage heart failure who are not candidates for transplant. Continuous-flow LVADs have high 1- and 2-year survival rates of 80% and 70% respectively. While LVADs improve survival and quality of life, patients face risks of complications like bleeding, infection, stroke, and device malfunction. Ongoing management requires careful monitoring and optimization of patient hemodynamics and medical therapies.
Survival in patients with advanced heart failure (AHF) has improved over the last 2 decades. An increasing number of patients however, are dying with progressive heart failure over the same duration. Optimal utilization of medical therapies and devices like implantable defibrillators and biventricular pacemakers are the likely reasons patients are surviving longer albeit with progressive HF.
Evolution in mechanical circulatory support (MCS) devices has occurred over the same period, such that they can now be rapidly instituted providing support for pump failure, often percutaneously, with timely restitution of physiologic and metabolic derangements with fewer complications.
MCS devices can be classified as Short term and Long term. Short term devices such as Intraaortic balloon pumps (IABP), Impella ®, TandemHeart® or Venoarterial extracorporeal membrane oxygenation (VA – ECMO) using a Cardiohelp® device, are usually employed as ‘Bridge to Recovery’(BTR) or Bridge to Decision’(BTD), usually in acute settings. Long term devices such as implantable left ventricular assist devices (LVADs) e.g. Heartmate II® & 3®, Heart ware HVAD® are implanted as ‘Bridge to transplant’ (BTT) or ‘Destination therapy’ (DT) usually in patients ‘sliding’ on inotropes when they are transplant eligible (BTT) or ineligible (DT) respectively.
Ventricular assist devices have traditionally been developed for left ventricular support in case of severe left heart or biventricular dysfunction. Historically, right ventricular (RV) dysfunction following LVAD implantation or as a component of biventricular dysfunction was managed with either medical therapy, temporary VADs (i.e. ECMO configuration with continuous flow centrifugal pumps like CentriMag®, Rotaflow ®) or occasionally with LVADs placed on the right side. Recently the Impella RP® and ProtekDuo®, percutaneously placed pumps with inflow in the inferior vena cava & right atrium respectively and outflow in pulmonary artery, have become available as less invasive options, for short term RV support.
The Syncardia® is the only approved total artificial heart system currently in use; however various biventricular, total heart systems (e.g. BiVACOR®) in development show promise.
Mechanical circulatory devices provide attractive, viable, physiologically plausible ventricular support options that can be used effectively in carefully selected patients.
This document discusses optimizing extracorporeal membrane oxygenation (ECMO) support. It begins by outlining the goals of ECMO as resuscitating patients, reducing infarct size, and saving lives. It then discusses standard and additional monitoring needed on ECMO, potential obstructions like thrombus, and optimizing gas exchange. Finally, it covers monitoring the haemodynamic effects of ECMO on the heart, decompressing the left ventricle, and determining readiness for weaning a patient off ECMO support.
Post cardiac surgery monitoring & follow upRubayet Anwar
This document provides information on post-cardiac surgery monitoring and follow up. It discusses admission to the ICU, initial assessment, monitoring techniques, complications that can occur like bleeding and hemodynamic issues, and management strategies for those complications. The early focus is on stabilizing vital signs, addressing hypothermia, identifying potential issues like low cardiac output, and treating medical causes of bleeding through correcting coagulation abnormalities.
Dr. Cravens CMC Implanted Device Imaging Mastery Project: ICD CasesSean M. Fox
This document discusses pacemakers and implantable cardioverter defibrillators (ICDs). It provides an overview of the indications for cardiac pacing and ICD placement. It then presents several cases showing normal anatomy and positioning of single chamber pacemakers, dual chamber pacemakers, single chamber ICDs, dual chamber ICD-pacemaker devices, and subcutaneous ICDs on chest x-rays. Readers are invited to test their knowledge of device identification on several example cases. The document promotes mastery of cardiac device imaging interpretation and ongoing medical education.
The document discusses coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy. It finds that CABG is associated with high early composite outcomes in these patients, but 5-year survival rates are good. A lack of improvement in left ventricular function after CABG is a strong predictor of late mortality. The study assessed early and mid-term outcomes of CABG in patients with ischemic cardiomyopathy.
This document provides an overview of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for adults. It discusses how VA-ECMO can support patients with refractory cardiopulmonary failure for weeks. It describes the hemodynamics of cardiogenic shock and how VA-ECMO impacts pressure-volume loops. It outlines strategies to reduce pulmonary congestion on VA-ECMO and lists contraindications and predictors of mortality. It also discusses the use of ECMO for cardiac arrest (ECPR) and criteria for its use for refractory ventricular tachycardia or cardiogenic shock.
This document discusses coronary artery bypass grafting (CABG), including indications, conduits used, and postoperative results. CABG is indicated for ischemic heart disease to relieve symptoms and improve survival. Common conduits are the internal thoracic artery, radial artery, and saphenous vein. Postoperative complications can include bleeding requiring reexploration (2-6% of cases), perioperative myocardial infarction (2-10% of first time CABG), neurologic events like delirium (30-80% at discharge), and stroke (incidence of 1-3%). Long-term patency of conduits is highest for the internal thoracic artery at 10 years.
This document discusses left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABP). It begins with definitions of mechanical circulatory support (MCS) and ventricular assist devices (VADs). It then provides a brief history of the development of these devices. The remainder of the document discusses the types, indications, patient selection considerations, components and surgical techniques for LVADs as well as post-operative management considerations like complications and anticoagulation therapy.
This document discusses the intra-aortic balloon pump (IABP), including its history, principles of function, indications, anatomy, techniques of insertion and removal, and key contributors. The IABP provides temporary left ventricular support by mechanically displacing blood within the aorta. It was first developed in the 1950s and used successfully in 1967. The document outlines the physiology effects of IABP therapy in increasing myocardial oxygen supply and decreasing demand. Common indications for IABP include cardiogenic shock and high-risk coronary interventions. The document reviews IABP device components, insertion techniques, optimal catheter positioning, and complications.
Which mechanical circulatory support should we use as first line optiondrucsamal
1) Temporary mechanical circulatory support options like intra-aortic balloon pumps, Impella pumps, TandemHeart pumps, and extracorporeal membrane oxygenation (ECMO) can be used as first-line support for acute cardiogenic shock.
2) These temporary options are placed percutaneously in the catheterization lab and can provide partial to full cardiac output support.
3) Larger ventricular assist devices require open heart surgery and are better suited for longer term chronic support if the patient does not recover with temporary support. The optimal support strategy depends on the individual patient's clinical status and prognosis.
The document provides an overview of several interventional procedures for treating valve diseases, including percutaneous aortic valve replacement, percutaneous mitral valve repair, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), cardiac devices like implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy (CRT), and artificial hearts. Key procedures discussed include replacing the aortic valve through a catheter in the femoral artery, repairing the mitral valve with a small metal clip, and implanting devices like ICDs, CRT pacemakers, and temporary artificial hearts.
Point-of-care cardiac ultrasound, also known as focused cardiac ultrasound (FoCUS), can be performed at the bedside by any treating clinician to evaluate hypotensive patients. It uses 2D ultrasound to visualize the heart's size, function and anatomy without advanced training or technology. FoCUS can differentiate shock types and guide fluid resuscitation by examining the heart, lungs and IVC for signs of volume status. A normal, collapsing IVC suggests hypovolemia while B-lines in the lungs discourage further fluids for possible edema. RV size helps diagnose pulmonary embolism. This review discusses the clinical applications and techniques of FoCUS to rapidly diagnose and treat unstable patients.
ECMO is a form of extracorporeal life support used for patients with severe cardiac or respiratory failure. It works by removing blood from the body, oxygenating it, and returning it. The document discusses the history and development of ECMO, components of the ECMO circuit, modes of ECMO including veno-venous and veno-arterial, indications and contraindications for its use, complications, and criteria for weaning patients off of ECMO support.
Digital Subtraction Neuroangiography: What a Resident Should Know Dr. Shahnawaz Alam
This document provides an overview of digital subtraction neuroangiography for residents. It begins with an introduction to the principles and importance of neuroangiography. It then provides detailed descriptions of normal neurovascular anatomy and angiographic views of the extracranial carotid system, anterior and posterior circulations. It discusses indications, contraindications, patient preparation, technique, complications and case examples to illustrate pathologies. The goal is to equip residents with the basic knowledge to interpret images and safely perform neuroangiography.
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EMGuideWire's Radiology Reading Room: Mechanical Circulatory Support Devices
1. Mechanical Circulatory
Support Devices
Blaire Langa, NP, Claire Lawson, NP,
Morgan Penzler, MD, Ashley Moore Gibbs, DNP,
Jenna Pallansch, MD, Gabriella Rivera Camacho, MD
Department of Emergency Medicine
Sanger Heart & Vascular Institute
Michael A. Gibbs, MD, Lead Editor
Richard Musialowski, MD, Cardiology Editor
Laszlo Littmann, MD, ECG Subject Matter Expert
Carolinas Medical Center Imaging Mastery Project: Cardiology
2. Disclosures
This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
The Sanger Heart & Vascular Institute provides expert Cardiology support.
The goal is to promote widespread mastery of CXR interpretation.
There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.
3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of chest X-ray/imaging case studies and discuss an
approach assessing patients with Mechanical Circulatory Support Devices.
7. Selected Embedded References:
Sternberg R. Targeted Evaluation of Patients With Left Ventricular Assist Devices and Shock or
Hypotension. Annals of Emergency Medicine. 2020; 76:34-41.
Devore AD. Medical Management of Patients With a Left Ventricular Assist Device for the Non-Left
Ventricular Assist Device Specialist. Journal of the American College of Cardiology. 2017; 5(9):621-631.
Long B. Left Ventricular Assist Devices And Their Complications. American Journal of Emergency
Medicine. 2019; 37:1562-1570.
Cook JL. Recommendations for the Use of Mechanical Circulatory Support: Ambulatory and Community
Patient Care. Circulation. 2017; 135:e1145–e1158. DOI: 10.1161/CIR.0000000000000507.
Kreiger J. The Use of ECMO in Cardiopulmonary Failure in Patients with COVID-19. Journal of the
American College of Cardiology. 2020. www.jacc.org. August 4, 2020.
Mehra MR. A Fully Magnetically Levitated Circulatory Pump for Advanced Heart Failure. New England
Journal of Medicine. 2017:376:440-50.
14. Read online:
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biventricular – and can be temporary or permanent, based on the clinical indication. Temporary
VADs are used as a bridge to myocardial recovery or during cardiac transplantation. Permanent
VADs may be used for the same reason but are typically selected in patients who require long-
term treatment for myocardial dysfunction and who are not fit for cardiac transplantation.
An intra-aortic balloon pump (IABP) is a polyethylene balloon that spans the entire length of the
thoracic aorta, placed percutaneously via femoral artery access. The IABP comes in different
lengths with IABP selection determined based on the patient’s height. The IABP inflates during
diastole leading to an increase in blood flow to the coronary arteries, great vessels and renal
arteries. Immediately prior to systole, it deflates producing a vacuum effect leading to forward
blood flow to the aorta and its branches. Although the IABP is predominately radiolucent on a
CXR, it has radiopaque tips proximally and distally. On the CXR, the cephalad radiopaque tip
should be 2 cm above the carina (Figure 1). An alternate landmark would be the aorto-pulmonary
window. Placing the IABP too caudally may occlude the celiac, superior mesenteric or renal
arteries, while placing it too high may occlude the brachiocephalic, subclavian or carotid arteries.
Complications that can occur with IABP include vascular (e.g. limb ischaemia, renal insufficiency,
mesenteric ischaemia and aortic dissection) and non-vascular (e.g. catheter-related [perforation,
tear and incorrect positioning] infection and neurological sequelae).3,4,5
15. 52-Year-Old With
With A History Of
Cardiac Sarcoid.
CXR Just Before
Heart Transplant.
Arrows Points To The Radiopaque Markers Of The IABP
16. 52-Year-Old With
With A History Of
Cardiac Sarcoid.
CXR Just Before
Heart Transplant.
Arrows Points To The Radiopaque Markers Of The IABP
21. Impella™
Percutaneous femoral artery access – device advanced into the left ventricle (LV)
LV blood drawn into the pump and released across the valve in the proximal aorta
Aortic flow rates up to 5.0 liters/minute
Increases cardiac output & coronary perfusion and decreases myocardial O2 consumption
28. ECMO
Indication: Acute, severe reversible respiratory or cardiac failure with a
high risk of death that is refractory to conventional therapies.
V-V = veno venous
V-A = veno-arterial
29. Figure 1: V-V ECMO
Blood is drained from the femoral vein
and returned to the right heart.
30. Figure 2: V-V ECMO
Central venous blood is drained, and
oxygenation blood is returned to the
right atrium.
31. V-V ECMO
Support for severe pulmonary failure (w/o cardiac failure).
Clinical Condition Appropriate For V-V ECMO
• Pneumonia
• ARDS
• Acute GVHD
• Pulmonary contusion
• Smoke inhalation
• Status asthmaticus
• Airway obstruction
• Aspiration
• Bridge to lung transplant
• Drowning
32. Figure 3: V-A ECMO
Central venous blood is drained, and
oxygenation blood is returned to the
arterial system.
33. V-A ECMO
Support for cardiac failure (+/- pulmonary failure).
Clinical Condition Appropriate For V-A ECMO
• Graft failure post heart or heart
lung transplant
• Non-ischemic cardiogenic shock
• Failure to wean post
cardiopulmonary bypass
• Bridge to LVAD
• Drug overdose
• Sepsis
• Pulmonary embolus
• Cardiac or major vessel trauma
• Massive pulmonary hemorrhage
• Pulmonary trauma
• Acute anaphylaxis
40. Implant Volumes Of Left
Ventricular Assist Systems
(LVAS) Reported To
INTERMACS (Interagency
Registry For Mechanically
Assisted Circulatory Support)
Registry 2006-2017.
41. U.S. LVAD Statistics
• Approximately 2,500 LVADs are implanted in the U.S. annually.
• Survival following implantation continues to improve, with a current
1-month survival rate of 95%, and 1 and 2-year survival estimates of
80% and 70% respectively.
• There are currently three durable LVADs approved by the FDA:
HeartMate II™ St. Jude Medical, St. Paul, MN
HeartMate III™ St. Jude Medical, St. Paul, MN
HeartWare™ HeartWare, Framingham, MA
42.
43. Basic LVAD Design
The HeatMate II™, HeartMate III™, and HeartWare™ are all continuous flow
devices with the following analogous components:
• An inflow cannula that is surgically implanted into the left ventricular apex
• A pump enclosure that houses and impeller that circulates blood
• An outflow cannula that carries blood from the pump to the systemic circulation
• A surgically tunneled driveline that connects the pump to the system controller
• The system controller is connected by 2 power cables to a battery powered source or
an AC power source when the batteries are charging
48. Key Differences Between Devices
HeartMate II™
• Axial flow
• Largest profile requiring implantation in preperitoneal pocket
HeartMate III™ and HeartWare™
• Centrifugal flow
• Smaller profile allows implantation in the chest
• More sensitive to preload and afterload than the HeartMate II™
• More accurate cardiac output
• “Speed modulation” (rapid slowing and then speeding up of the impeller):
reduces the risk of in situ pump thrombosis, and aortic valve insufficiency
49. Basic LVAD Function
• LVADs move blood from the LV apex to the systemic circulation in a
continuous (non-pulsatile) manner
• Pump speed is the fundamental parameter that the provider can alter
• As pump speed increases the impeller within the pump housing spins
more rapidly and circulates a greater volume of blood, thereby increasing
LV unloading and cardiac output
• The system controller estimates cardiac output indirectly based on speed
and power consumption
50. Rotor
bearing
Rotor bearing
Inflow
cannula
B Control Device—Axial-Flow Pump
Blood
flow from
left ventricle
Blood flow
to aorta
Rotor
Inlet stator and
blood-flow
straightener
Motor
Pump
housing
Outlet stator
and diffuser
Percutaneous
drive line
Left
ventricle
Aorta
Heart
Pericardial
sac
Outflow
graft
Diaphragm
Percutaneous
drive line connects to
external battery pack
and controller
Axial-flow pump
designed for
intraabdominal
placement
HeartMate II™
Axial Flow
51. Read online:
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biventricular – and can be temporary or permanent, based on the clinical indication. Temporary
VADs are used as a bridge to myocardial recovery or during cardiac transplantation. Permanent
VADs may be used for the same reason but are typically selected in patients who require long-
term treatment for myocardial dysfunction and who are not fit for cardiac transplantation.
An intra-aortic balloon pump (IABP) is a polyethylene balloon that spans the entire length of the
thoracic aorta, placed percutaneously via femoral artery access. The IABP comes in different
lengths with IABP selection determined based on the patient’s height. The IABP inflates during
diastole leading to an increase in blood flow to the coronary arteries, great vessels and renal
arteries. Immediately prior to systole, it deflates producing a vacuum effect leading to forward
blood flow to the aorta and its branches. Although the IABP is predominately radiolucent on a
CXR, it has radiopaque tips proximally and distally. On the CXR, the cephalad radiopaque tip
should be 2 cm above the carina (Figure 1). An alternate landmark would be the aorto-pulmonary
window. Placing the IABP too caudally may occlude the celiac, superior mesenteric or renal
arteries, while placing it too high may occlude the brachiocephalic, subclavian or carotid arteries.
Complications that can occur with IABP include vascular (e.g. limb ischaemia, renal insufficiency,
mesenteric ischaemia and aortic dissection) and non-vascular (e.g. catheter-related [perforation,
tear and incorrect positioning] infection and neurological sequelae).3,4,5
52. HeartMate™ II
Pump Below The Diaphragm (Arrow)
Left Ventricular Inflow Cannula (Arrow)
Inflow Cannula
(Arrow)
Outflow Cannula
(Arrowhead)
57. Read online:
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biventricular – and can be temporary or permanent, based on the clinical indication. Temporary
VADs are used as a bridge to myocardial recovery or during cardiac transplantation. Permanent
VADs may be used for the same reason but are typically selected in patients who require long-
term treatment for myocardial dysfunction and who are not fit for cardiac transplantation.
An intra-aortic balloon pump (IABP) is a polyethylene balloon that spans the entire length of the
thoracic aorta, placed percutaneously via femoral artery access. The IABP comes in different
lengths with IABP selection determined based on the patient’s height. The IABP inflates during
diastole leading to an increase in blood flow to the coronary arteries, great vessels and renal
arteries. Immediately prior to systole, it deflates producing a vacuum effect leading to forward
blood flow to the aorta and its branches. Although the IABP is predominately radiolucent on a
CXR, it has radiopaque tips proximally and distally. On the CXR, the cephalad radiopaque tip
should be 2 cm above the carina (Figure 1). An alternate landmark would be the aorto-pulmonary
window. Placing the IABP too caudally may occlude the celiac, superior mesenteric or renal
arteries, while placing it too high may occlude the brachiocephalic, subclavian or carotid arteries.
Complications that can occur with IABP include vascular (e.g. limb ischaemia, renal insufficiency,
mesenteric ischaemia and aortic dissection) and non-vascular (e.g. catheter-related [perforation,
tear and incorrect positioning] infection and neurological sequelae).3,4,5
58. 18-Year-Old Female Transferred To CMC In Respiratory Failure After Emergent C-Section.
Chest X-Ray 1 Year Ago
Hospital Day #1
59. 18-Year-Old Female Transferred To CMC In Respiratory Failure After Emergent C-Section.
Hospital Day #2: Worsening Respiratory Failure And Shock
60. 18-Year-Old Female Transferred To CMC In Respiratory Failure After Emergent C-Section.
Hospital Day #5: Successfully Implanted HeartMate III™ LVAD As A Bridge To Transplant
67. A StudyDevice—Centrifugal-Flow Pump
Pericardial
sac
Blood flow to aorta
Outflow graft
Left
ventricle
Aorta
Heart
Diaphragm
Short inflow
cannula
Motor
Pump
housing Percutaneous
drive line
Magnetic
hydrodynamically
levitated impeller
Percutaneous
drive line connects to
external battery pack
and controller
Blood flow from
left ventricle
40mm
Centrifugal-flow
pump designed for
intrapericardial
placement
HeartWare™
Centrifugal Flow
68. Read online:
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biventricular – and can be temporary or permanent, based on the clinical indication. Temporary
VADs are used as a bridge to myocardial recovery or during cardiac transplantation. Permanent
VADs may be used for the same reason but are typically selected in patients who require long-
term treatment for myocardial dysfunction and who are not fit for cardiac transplantation.
An intra-aortic balloon pump (IABP) is a polyethylene balloon that spans the entire length of the
thoracic aorta, placed percutaneously via femoral artery access. The IABP comes in different
lengths with IABP selection determined based on the patient’s height. The IABP inflates during
diastole leading to an increase in blood flow to the coronary arteries, great vessels and renal
arteries. Immediately prior to systole, it deflates producing a vacuum effect leading to forward
blood flow to the aorta and its branches. Although the IABP is predominately radiolucent on a
CXR, it has radiopaque tips proximally and distally. On the CXR, the cephalad radiopaque tip
should be 2 cm above the carina (Figure 1). An alternate landmark would be the aorto-pulmonary
window. Placing the IABP too caudally may occlude the celiac, superior mesenteric or renal
arteries, while placing it too high may occlude the brachiocephalic, subclavian or carotid arteries.
Complications that can occur with IABP include vascular (e.g. limb ischaemia, renal insufficiency,
mesenteric ischaemia and aortic dissection) and non-vascular (e.g. catheter-related [perforation,
tear and incorrect positioning] infection and neurological sequelae).3,4,5
69. 53-Year-Old Diabetic With Non-Ischemic Biventricular Failure
HeartWare™ LVAD As A Bridge To Transplant
71. History
• Recent device parameters, alarms, symptoms of infection or heart
failure, signs of hemoglobinuria (could indicate LVAD thrombosis),
signs/symptoms of GI bleeding
• Evaluate tolerability to anti-thrombotic medications (usually aspirin,
warfarin)
• Call your LVAD coordinator early for assistance with management
72. Physical Examination
• Heart rate, blood pressure, drive line, device connections
• Auscultation for “whir” of LVAD pump:
• Degree of arterial pulsatility depends on AV function, LVAD pump
speed, LVAD preload and afterload, underlying LV contractility
Whir Absent Pump Malfunction
Whir Loud Consider Driveline Thrombosis1
1The device may be warmer to touch than usual
73. Physical Examination
• At high pump speeds continuous flow predominates, decreasing pulsatility
• Pulses may not be palpable, and standard cuffs will not be effective in
measuring the patient’s blood pressure
• Measure blood pressure using doppler… inflate the cuff and deflate until
doppler sounds are heard
• Audible doppler signal approximates mean arterial pressure [MAP]
74. ED Diagnostic Testing
Labs: in addition to usual INR, LDH (2.5x upper limit of normal, >600 IU or
significantly above baseline suggests hemolysis). Dark, tea-colored urine is a
marker of device thrombosis and ongoing hemolysis.
CT: evaluate for deep space infection, and can assess LVAD components
ECHO:
• Evaluation for aortic insufficiency, inflow cannula position, RV, LV function
• Can get real-time feedback on adjustments in speed, pacing, positional changes,
provocative movements like valsalva
• Can be limited by acoustic shadowing from LVAD components
75. THE ECG IN PATIENTS WITH
LEFT VENTRICULAR ASSIST DEVICES
Dr. Laszlo Littmann, MD
Department of Internal Medicine
Carolinas Medical Center
December 2020
77. • In HeartMate 3, an electromagnetic rotor is spinning at
5,000-6,000 rpm, driving the blood from the LV apex to the
ascending aorta
• The ECG in these patients, therefore, always demonstrates
very high frequency gross artifact, which makes the ECGs
essentially unreadable
• Changing the filter settings of the recording, however, can
clean out most high frequency artifacts
• The low-pass filter should be changed from 150 Hz to 40 Hz
• This maneuver can be easily performed even after the ECG
was already recorded by using the following steps:
78. • Cerner-PowerChart
• Find the patient (name or MRN)
• Provider Workflow
• Diagnostics
• Cardiology
• ECG Electrocardiogram
• Click on the current ECG
• Click on the icon at the right upper corner (gain and filter settings)
• Change the filter setting from 150 Hz to 40 Hz
• At a low-pass filter of 40 Hz, most high frequency artifacts will
disappear
• Unfortunately, pacemaker spikes may also become invisible
79.
80. ECG OF SAME PATIENT WITH LOW-PASS FILTER
CHANGED FROM 150 HZ TO 40 HZ
81.
82. LVAD Complications
• More than 50% of patients are readmitted in the first 6 months
following LVAD implantation
• The most common complications are infection, bleeding and
dysrhythmia
• 80% of patients will experience a complication within the first 2 years
83.
84. Complications: Non-Surgical Bleeding
Risk Factors:
• Use of antithrombotic therapy [INR keep at 2.0 – 3.0]
• Acquired von Willibrand deficiency - vW factor polymers degraded
during flow through the LVAD pump
• Formation of AV malformations related to continuous blood flow and
associated abnormal regulation of angiogenesis1
1Gastrointestinal bleeding from AVMs the most common presentation
85. Complications: Non-Surgical Bleeding
Management:
• Immediate consultation with the LVAD team
• Hold antithrombotic therapy
• Control bleeding site if possible
• Transfusion based on clinical status – 1st determine the patient’s
transplant status [appropriate blood product preparation]
• Early involvement of Gastroenterology for GI bleeding
• In severe bleeding reversal of anticoagulation [4-factor PCC] is safe
86.
87. Complications: Infections
• The majority of infections involve the percutaneous driveline that is a
vulnerable site for local trauma from tension on the line (e.g.:
dropping battery pack)
• Skin pathogens (coagulase [-] staph, S. aureus) are most common,
although Gram [-] organisms (Pseudomonas, Enterobacteriaceae),
fungal, and polymicrobial infections can also occur
90. Complications: Dysrhythmia
• LVAD patients can tolerate dysrhythmias for long periods due to the
device’s circulatory support
• Hypovolemia can precipitate “suction events” whereby the LVAD left
ventricular inflow cannula contacts the ventricular free wall – these
patients often present with ventricular tachycardia and Rx = volume
resuscitation
Atrial Fibrillation 50%
Ventricular Dysrhythmias 22% -58%
91. Complications: Dysrhythmia
Evaluation And Management:
• Assessment similar to the non-LVAD patient
• Immediate ECG and early ECHO
• Cardioversion safe
• Avoid placing defibrillator pads directly over the pump or driveline
• The LVAD pump remain running during cardioversion
92. Complications: LVAD Malfunction
Electrical Malfunction
• Presents with alarm and pump
stoppage
• Evaluate alarms, patient stability,
LVAD flow
• Ensure connections are secure
• Consult LVAD team at once
Pump Thrombosis
• Hematuria indicative of hemolysis
• Inflow, pump, or outflow sites
• Evaluate INR and antithrombotic
medications
• STAT ECHO to evaluate LVAD
dysfunction
93. Complications: Stroke [Ischemic, Hemorrhagic]
• Bimodal: 1st peak perioperative; 2nd peak 1-year post-implantation
• 9% annual risk
• Pump thrombosis a risk for embolic stroke
• Urgent CT-A head and neck
Management:
Hemorrhagic Reversal of anticoagulation, Neurosurgery, LVAD team consultation
Thrombotic Evaluate for IV TPA and/or mechanical thrombectomy
96. Left Middle Cerebral
Artery Territory Stroke
Right Posterior Cerebellar
Artery Territory Stroke
50-Year-Old Male With Right-Sided Weakness And Dizziness
97. Bilaterality Suggests An Embolic Source
Left Middle Cerebral
Artery Territory Stroke
Right Posterior Cerebellar
Artery Territory Stroke
98.
99. Complication: Heart Failure
• Always consider aortic valve insufficiency when LVAD patient present in
heart failure, since even a small opening can lead to large volume
regurgitation and a futile circuit from the LV to the pump to the outflow
tract to the aorta right back into LV
• Heart failure “location” [assessed by history, exam, ECHO] drives care:
• Biventricular
• Left ventricular
• Right ventricular
100. Biventricular Heart Failure
• Evaluate for LVAD dysfunction/thrombosis
• Vasodilators if elevated BP
• Inotropic support if evidence of low output or severe aortic insufficiency
• Increase LVAD speed
• Diuresis
Left Ventricular Heart Failure
• Evaluate for LVAD dysfunction/thrombosis
• Vasodilators if elevated BP
• Inotropic support if evidence of low output or severe aortic insufficiency
• Increase LVAD speed
• +/- Diuresis
Right Ventricular Heart Failure
• Diuresis
• Inotropic support
• Pulmonary vasodilators
• Consider right-sided mechanical circulatory support in transplant candidates with refractory HF
• Palliative care consult
101.
102.
103.
104.
105.
106.
107.
108.
109. If You Have Interesting Cases Demonstrating Mechanical Circulatory Support
Devices, We Invite You To Send A Set Of Digital PDF Images And A Brief
Descriptive Clinical History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!